Ultrasound Podcast – Cardiac Arrest with Cian McDermott, Part 1

This week we get to hear from Cian McDermott, ED physician extraordinaire on his approach to cardiac arrest.  In this podcast we discuss 1 vs 2 person POCUS, different ways to use it during arrest, and some of our favorite published protocols.  There was so much great content in this interview, so I decided to break it up into 2 podcasts. This week features part 1! (Click here for Part 2)

Look down below for the show notes, courtesy of Cian McDermott!

Important topic – why?

  • work in ED see several OOHCA per week
  • my service 3 to 5 per week
  • 10 – 15% survival rate in best centres (Danish 15 yr study)
  • can we manage this better using POCUS?
  • Concept has been around but lots of new literature in 3 years

Caution

  • POCUS is not for shockable rhythm
  • put down the transducer and give electricity!
  • conside for reversible arrest only = PEA, asystole (5Hs & 5Ts)

 

2 user levels

Level I user – most ppl

  • US during pulse check only
  • SubX window
  • maybe confirm asystole at end
  • first time I saw POCUS in code like this was in Australia in 2014

Level 2

  • may have been to EGLS course
  • looking for reversible causes
  • tamponade, signs RV strain then cardiac activity
  • SubX or PSLA view
  • starts before the end of CPR to minimise delays

 

What does the evidence say?

  • ACLS from 2015 cites a single study and they recommend that US may be used during an arrest, they give class II evidence for this
  • I had to hunt on the website to find this – ACLS are ‘lukewarm’
  • ACLS will be updated in 2020 so I’m waiting to see what changes are recommended
  • European and American Society produced guidelines on use of POCUS
  • Huis published a paper in that involved filming an actual arrest scenario and then measuring times involved (Huis In ‘t Veld et al. 2017)
  • group that used POCUS had 21s for the pulse check
  • group that did not use POCUS had 13s pulse check
  • discussed this on UltrasoundGEL podcast in 2017
  • raises important question – are we causing delays by using POCUS?
  • Need to do it better consistently 
  • Romolo Gaspari’s paper from the REASON network (Gaspari et al. 2016)
  • Gaspari was interviewed about this on ultrasound podcast at time of publication
  • changes the way I think about POCUS in a code
  • 20 sites, almost 800 patient *asystole *PEA *out of hospital or in ED * did scan #1 at start and scan #2 at end of code
  • If you have activity on US then associated with survival to discharge OR 5.7
  • If no cardiac activity – 0.6% survival rate to discharge
  • How does this help IRL? Helps us prognosticate – help decide if we should stop
  • Asystole is wrong 10% cases – there was cardiac activity on the 1st US
  • PEA has cardiac activity in 54% cases – may not be pulseless
  • justifies the use of POCUS every time in a code
  • CASA protocol from Arun Nagdev’s group in Highland (Clattenburg et al. 2018)
  • Cardiac Arrest Sonographic Activity study
  • Really neat protocol that fits right into ACLS framework
  • Check for tamponade at 1st pulse check (10s)
  • Next pause, look for RV strain pattern
  • Next pause look for cardiac activity
  • Post implementation data how some great reductions in pulse check duration in their – 4s on average when this protocol was used
  • Solves the delay in pulse check problem for me

Another protocol in the Australian literature that was published in 2019

  • COACHRED menemonic (Finn et al. 2019)
  • (Stands for Continue compressions, Oxygen support, All else stand clear, Charge Defib, Hands off compressions)
  • Then the US piece Rhythm check, Record Echo, then off, deliver shock or dump the charge
  • Simulation based protocol
  • Main difference with this one is that it is used for shockable and non shockable arrests so that’s why the sono person stands clear for the shock
  • Another great algorithm that integrates to ACLS but they advocate that only echo during the pulse check – I disagree there is lots more info from intra-arrest ECHO
  • Great to specify a sequence of events in a code for all users

That pig study 2016 (Anderson et al. 2017)

  • VF induced in 2 group of pigs – the group that had CPR performed over centre of LV had inc rate of ROSC and better ETC02 readings
  • group that had CPR over aortic root did worse
  • Standard position is in centre of the chest – should we tailor CPR based on LV compression & recoil that you see if you use intra-arrest CPR
  • YES, why not!
  • Extrapolate to humans = caution

Lots of other ELS acronyms

  • FATE = focussed assessed transthoracic echo *early one
  • FEEL = focussed echo in emergency life support *UK based exam
  • FEER = focussed echo in evaluation of resuscitation
  • CAUSE = cardiac arrest US exam

Where do I go if I want to read more about this area? Are there any high-yield papers about this?

2 great papers about it POCUS at a CODE

  • Rachel Liu from Yale – published last year in prehospital journal – really practical tips on the ‘how to’ of POCUS in a code plus 5 amazing cases (Liu et al. 2019)
  • Laila Hussein’s paper just hot off the press at the end of December – great run down of key topics (Hussein et al. 2019)